Characteristics and outcomes of small bowel adenocarcinoma: 14 years of experience at a single tertiary hospital in Saudi Arabia
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MOLECULAR AND CLINICAL ONCOLOGY 18: 17, 2023
Characteristics and outcomes of small bowel adenocarcinoma:
14 years of experience at a single tertiary hospital in Saudi Arabia
BADER ALSHAMSAN1,2, MOHAMED ASEAFAN1,3, AHMED BADRAN1,4, AMGAD SHAHEEN1,5,
MAHMOUD A. ELSHENAWY1,6, SHOUKI BAZARBASHI1 and ALI H. ALJUBRAN1
1
Section of Medical Oncology, Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh 11211;
2
Department of Medicine, College of Medicine, Qassim University, Buraidah 51432; 3Section of Medical Oncology,
Department of Internal Medicine, Security Forces Hospital Program, Riyadh 11481, Saudi Arabia; 4Clinical Oncology and
Nuclear Medicine Department, Faculty of Medicine, Ain Shams University, Cairo 11517; 5Medical Oncology Department,
National Cancer Institute, Cairo University, Cairo 12613; 6Clinical Oncology Department, Faculty of Medicine,
Menoufia University, Shebin El Kom 32511, Egypt
Received September 5, 2022; Accepted December 22, 2022
DOI: 10.3892/mco.2023.2613
Abstract. Small bowel adenocarcinoma (SBA) is an extremely addition to the stage, the Eastern Cooperative Oncology Group
rare cancer type. In the present study, the patient characteris‑ Performance Status (P2 ALSHAMSAN et al: CHARACTERISTICS AND OUTCOMES OF SBA
Overall, there are limited studies regarding the disease char‑ Results
acteristics and outcomes of SBA, particularly from the Arab
regions, due to the rarity of the disease. In the present study, Patient characteristics. Of 137 small bowel primary tumors
the patient characteristics and clinical outcomes for patients diagnosed during the study period, 43 cases of SBA were
with SBA treated at our tertiary hospital were described. identified and included in the analysis. The median age at
diagnosis was 53 years (range, 44‑66 years) and the majority
Materials and methods of patients (76.7%) were males. The detailed patient and
disease characteristics are presented in Table I. The most
Patients and methods. A retrospective review of consecutive common primary site was the duodenum (60.5%), followed
patients diagnosed with SBA between January 2007 and by the jejunum (27.9%) and ileum (6.9%). The most common
December 2020 at King Faisal Specialist Hospital & Research diagnostic modalities were EGD (60.5%) and CT scan
Center (Riyadh, Saudi Arabia) was performed. Study data (23.3%). The diagnosis was established intraoperatively in
were collected and managed using REDCap electronic data eight patients. The tumor markers were elevated in 21 patients
capture tools hosted at King Faisal Specialist Hospital & (48.8%): CEA was elevated in 10 patients (23.3%) and CA19‑9
Research Center (Riyadh, Saudi Arabia) (14,15). Ethical was elevated in 17 patients (39.5%). Furthermore, 18 patients
approval was obtained from the Research Ethics Committee (41.9%) presented with synchronous metastasis and the most
at King Faisal Specialist Hospital & Research Center (Riyadh, common sites for metastases were the liver (n=10 patients),
Saudi Arabia) and the requirement for informed consent followed by peritoneum (n=8), lung (n=8), lymph nodes (n=5)
from the patients was waived. The data obtained included and bone (n=2) (data not shown).
age at diagnosis, sex, Eastern Cooperative Oncology Group
Performance Status (ECOG PS), past medical and surgical Factors associated with metastatic stage at diagnosis.
history, family history, baseline laboratory test results, TNM The continuous values of baseline albumin (P=0.01), NLR
staging, management and outcomes, including best responses (P0.85 and that for PLR was >125 (Fig. S1). Univariate logistic
Cancer Control staging system (17). The disease response regression was significant for hypoalbuminemia [odds ratio
was evaluated using the Response Evaluation Criteria in (OR): 3.75, 95% CI: 1.01‑13.7; P=0.04] and high NLR (OR:
Solid Tumors (version 1.1) (18). Disease‑free survival (DFS) 20.2, 95% CI: 2.2‑182.4; P27 U/ml) FOLFOX, 5 patients). The median duration of chemotherapy
was present. Hypoalbuminemia was defined as an albumin was 3.75 months (range, 0.5‑6.0 months). A total of 9 patients
levelMOLECULAR AND CLINICAL ONCOLOGY 18: 17, 2023 3
Table I. Patients and disease characteristics (n=43).
Characteristic Value
Median age at diagnosis, years 53 (44‑66)
Male sex 33 (76.7)
PMH
Celiac disease 3 (6.9)
Lynch syndrome 1 (2.3)
Familial adenomatous polyposis 1 (2.3)
Multiple colonic polyps (non‑APC) 1(2.3)
PSH
Cholecystectomy 7 (16.2)
Hemicolectomy 6 (13.9)
Presentation
Figure 1. Kaplan‑Meier curves of overall survival of patients with localized
Abdominal pain 24 (55.8) and metastatic small bowel adenocarcinoma.
Vomiting 17 (39.5)
Bowel obstruction 13 (30.2)
Anemia 12 (27.9)
progressive disease (n=5) and unknown in 3 patients. A total
Overt gastrointestinal tract bleeding 5 (11.6)
of 6 patients underwent surgery (R0, 2 patients) and 2 received
Weight loss 8 (18.6)
radiation therapy. Furthermore, 3 patients received second‑line
Jaundice 5 (11.6)
chemotherapy (data not shown).
Baseline laboratory parameters, and
normal values Survival outcomes. The median duration of follow‑up was
Hb, g/dl (NR, 11.6‑16.6) 10.5 (7.8‑12.2) 12 months (range, 2‑47 months). The median DFS for patients
CEA, µg/l (NR, 0‑4.3) 2.15 (1.6‑4.2) who achieved complete resection (R0 vs. R1) was 49 vs.
CA19‑9, U/ml (NR, 0‑27) 30 (12‑77) 5 months (P=0.02). The median OS for localized disease
Albumin, g/l (NR, 34‑54) 34 (30.9‑38.7) vs. metastatic stage was not reached vs. 10 months and the
Bilirubin, mg/dl (NR, 0.1‑1.2) 6 (4.0‑9.5) 3‑year OS was 74.3 vs. 33.9%, respectively (P4 ALSHAMSAN et al: CHARACTERISTICS AND OUTCOMES OF SBA
Figure 2. Kaplan‑Meier curves of overall survival in patients with small bowel adenocarcinoma stratified by (A) stage, (B) ECOG PS, (C) NLR and (D) albumin
level. ECOG PS, Eastern Cooperative Oncology Group Performance Status; NLR, neutrophil‑lymphocyte ratio.
lation. In contrast to the young age at diagnosis in the present survival outcomes. Of note, high CA19‑9 was associated
cohort (50% were younger than 55 years), other studies have with a trend of longer survival that was more pronounced
found SBA to primarily be a disease of the elderly (3,12,13,21). in advanced settings, but it was not statistically significant
SBA tends to occur more frequently in males (6,7,9,10,22), (P=0.06). However, high CA19‑9 was associated with
consistent with the present cohort. However, certain studies shorter OS, particularly in the advanced stage (12,29).
reported a relatively equal distribution by sex (12,13,21). There Hypoalbuminemia in the present cohort exhibited an
was no association between sex and survival outcomes in the association with a more advanced stage at diagnosis and a
present cohort; however, male sex was previously reported to significant association with worse OS, consistent with the
be associated with worse survival outcomes in SBA (3,23). report by Sakae et al (28). Furthermore, a previous report
A total of 30.2% of the patients of the current study also indicated that high lactate dehydrogenase is a prognostic
presented with bowel obstruction or overt bleeding (11.6%), factor for poor OS (28).
perhaps due to late presentation. These rates are similar to The NLR reflects the underlying inflammatory and
those of previous studies (6,24‑26). Of note, 16.2% of the immunity processes, two essential parts of the hallmarks of
patients of the present study had a history of cholecystectomy; cancer (30). The NLR has been proven to have prognostic
in two‑thirds of them, the duodenum was the primary site and survival value in a variety of solid tumors, including gastroin‑
it was the jejunum in one‑third. The Swedish registry included testinal malignancies (31,32). Recently, two studies indicated
a quarter million patients who underwent cholecystectomy and that a high NLR is associated with poor survival outcomes
reported a significant increase in small intestine cancers after in patients with SBA (13,33). Yanko et al (13) used 4.5 as the
surgery that correlated with the distance from the common optimal cutoff for the NLR. They selected 4.5 based on the
bile duct (4,27). high median NLR in their cohort and the optimal NLR cutoff
The findings of the present study were similar to those of (median 3.5‑4.5) of a previous study (34). However, that study
previous studies that reported the benefit of R0 resection in terms included metastatic diseases and did not consider cancer site
of prolonged survival outcomes in metastatic settings (10,11). specificity (34). In the cohort of the present study, the median
Patients with advanced stage and poor ECOG PS had worse NLR was 1.46 and it was prespecified that the optimal NLR
OS, consistent with other reported series (2,8,21,22,25,28). would be obtained from the ROC curve (19,20). However, in
Nearly half of the patients of the present study had the present cohort, patients with NLR >4.5 had worse survival,
increased tumor markers, which were not associated with with a 3‑year OS of 16.7 vs. 63% (PMOLECULAR AND CLINICAL ONCOLOGY 18: 17, 2023 5
NLR in this cohort demonstrated an association with the Competing interests
metastatic stage at diagnosis, reflecting the aggressiveness of
the disease. Despite the small sample size, the present results The authors declare that they have no competing interests.
support the value of the NLR as an available biomarker that
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